Warning: You Could be Pre-Pregnant

What ethical complications arise when physicians imagine all women of reproductive age to be potential moms, whether or not these women ever want or plan to become pregnant?

That’s what worries University of South Florida philosophy and internal medicine professor Rebecca Kukla. She says that the “preconception care movement”–the recent push by organizations such as the March of Dimes, the Office of Minority Health and the American Pregnancy Association, along with health initiatives like Every Woman California, to offer prenatal care to all women has troubling implications, particularly for the low-income, minority women who are the movement’s target.

The seeds of this initiative were planted in 2006 when the Centers for Disease Control (CDC) released its “Recommendations to Improve Preconception Health and Heath Care” as part of its Morbidity and Mortality Weekly Report. One of the goals of the recommendations was to “assure that all women of childbearing age in the United States receive preconception care services,” and the CDC pushed implementation of the recommendation as part of the U.S. Department of Health and Human Service’s “Healthy People 2010″ objectives.

On the surface, preconception care sounds positive. When women visit their doctors they will receive “education on fertility, screening for HIV/AIDS and counseling on lifestyle modifications that improve pregnancy outcomes,” Kukla explains. Preventative care is a positive thing and it makes sense to promote healthy behaviors and eliminate risk factors that can result in premature births, low birth weights or infant mortality.

What is troubling, however, is that preconception care sends a potentially coercive message that pregnancy should necessarily result in birth or that, as Kukla puts it, “the ‘purpose’ of women’s health care is the protection of babies and society.” Said Kukla in a recent talk [PDF] at SUNY Binghamton:

The goal [of preconception care] is to reinterpret primary care for women with childbearing capacity as preconception care, regardless of whether they intend to become pregnant. It literally treats the non-pregnant body as on its way to pregnancy. Do lesbians, women who are carefully contracepting and not interested in having children, 13 year olds, women done having kids, really want their bodies seen as prenatal, understood in terms of reproductive function?

When women’s bodies are viewed as always “pre-pregnant,” physicians may treat light alcohol use or recreational drug use–behaviors that are acceptable for men–as irresponsible. Similarly, women may be expected to go on diets for the sole purpose of creating a more hospitable womb. Organizations such as the LA Best Babies Network remind us that “foods high in fat and sugar don’t help babies grow,” but what are the social implications of asking non-pregnant women to think about children every time they take a bite–particularly if those women are struggling to survive financially? Healthy eating can be expensive, and it may be difficult for women in poverty–the very targets of preconception care campaigns–to eat nutritious meals without additional financial assistance.

Early advocates of preconception care knew that it would be a “hard sell” for sexually active women who aren’t planning on becoming pregnant, says Kukla, so organizations such as the March of Dimes re-branded preconception care as something that is not solely about fetal health [PDF].

Preconception care’s pro-natal message is still obvious, however, and deeply troubling, particularly at a time when abortion bans are limiting women’s access to safe, legal abortions; when crisis pregnancy centers are proliferating across the U.S.; and when pregnant women are dying because they cannot afford vital prenatal services.

Kukla also observes that preconception care has the potential to compromise the quality of care regularly available to women, since it views women in terms of “reproductive lifespan” –a period of life that begins in adolescence and ends around the age of 44:

Treating chronic conditions … so as to maximize (potential) fetal outcomes is not always best for the woman. Interpreting everything through the lens of reproductive health skews which conditions we care most about and whose health we prioritize. Where do these initiatives leave care for women who can’t get pregnant–transgendered, post-hysterectomy, etc.? Is their need for diabetes control, substance abuse treatment … any less important? [And what about] care for women who are past ‘reproductive lifespan’? End of reproductive life and the end of life are equated in much of the preconception literature.

The goal of reducing maternal and infant mortality and morbidity is a good one, but preconception care initiatives seem less interested in improving access to comprehensive, quality health care for all women than in preparing women of the “right” age to reproduce.

While I agree that we should not consider "healthy babies" the goal of women's health care, I somehow doubt doctors are currently unaware of women's wombs and encouraging recreational drug use, mcdonald's diets, or lackadaisical care of diabetes. Also, lesbians and 13 year olds can get pregnant *and* not abort.

This just further illustrates the necessity of PLANNED parenthood. Women should be in control of their reproductive choices, encouraged to explore and use the methods of pregnancy prevention that work best for them, and then they will have a specific time and "pre-pregnancy" period in which to begin these additional care measures.

I get the point that women should not be treated as vessels just waiting to be impregnated, but the part about poor women not being able to eat healthy is complete crap. And it should have nothing to do wtih babies, but their own care for their own health. Eating healthy is really not expensive. A weeks worth of homemade, healthy meals can be achieved with 20 bucks (for recipes check out the blog cheaphealthygood.blogspot.com). Not to mention the fact that the dollar menu will lead to very expensive health costs further down the line, costs comparable to, say, having a child?

Thank you for your feedback. You're absolutely right that healthy eating can be affordable for many people who have time to cook, who don't live in a food deserts and who can fork out a little extra money for healthy fruits and vegetables (or who have internet access to find healthy recipes?). It would be great if ignorance were the only problem here or if access to healthy foods for all people was simply a matter of will.

It's the produce that comes with eating healthy that's expensive. I eat a salad every night at dinner, and have two to three pieces of fruit everyday, minimum. That right there, just for me, costs about $40. And that $40 can take a chunk out of a budget.

I can see both sides of this. Women who aren't planning to get pregnant do sometimes get pregnant and choose to carry to term. At the same time, women who do not ever plan to be pregnant should not be forced to hear about fertility and how to keep their bodies healthy for pregnancy. One-size-fits-all medical care is never the answer, but in some cases, the unexpected happens, and you need to be prepared.

The problem with these initiatives is that we should be promoting standards of care in which doctors have personal relationships with each patient as individuals not as part of a demographic. Doctors should be well aware of each patient’s health history, their current health issues and goals and their life plans and goals, including but continuing far beyond potential parenthood. Of course, building and maintaining a relationship with a doctor within our insurance-coverage delineated (and limited) system is difficult if not impossible for many, so instead we get blanket initiatives that aren’t about treating whole people.

This is also undoubtedly borne out of the medical perspective that all women want babies, even if they just don’t know it yet. We see the other side of that when younger women, especially without children, are outright denied access to sterilization procedures (unless they have a disability, which is another issue). We’ve long been viewed by the medical establishment as walking wombs, we really don’t need initiatives in this day and age, that reinforce that outdated notion. Women are more than our reproductive capacity.

I definitely have experienced this type of health care mentality. I was given pre-natal vitamins once at a routine OG/GYN exam (where, ironically, I requested a prescription for oral contraceptives) and advised to take them daily. I was 17. I freaked out and threw them away- if the point was to encourage a healthy lifestyle, it might have been more prudent to advise me to take a daily multi-vitamin, instead of giving me pre-natals when I clearly had no intention of becoming pregnant. I also disagree with the idea that all women should be treated as if they might get pregnant at any moment- and that an unplanned pregnancy somehow needs to be planned for medically by your doctors. I understand that in general there is a lack of planning for pregnancy and parenthood amongst women of all ages/races/class and so perhaps these practices developed out of those scenarios, but it's also not my doctor's right or place (nor is it anyone's right besides my own) to assume that an unplanned pregnancy would be one I would carry to term. Why not initiate pre-natal care or what pre-conception care is possible when the woman expresses her desire to carry a pregnancy to term?

What about women who can not have children? What about those of us who are on the cusp of being "too old" technically to have children? This is the stupidest and most insensitive, asinine idea EVER. I will have no problem telling my MD that I want to be treated as ME, not some damn baby maker. It's a shame they don't list which Health Insurance companies are pushing this. I'd LOVE to tell mine where to go with this idea and what to do there with it.

Interesting article. Just to note, however, that Ms. Kukla works at the University of South Florida, not Southern Florida. My alma matter doesn't usually get neutral or positive mention in feminist magazines.